Delivering better oral health: an evidence-based toolkit for prevention. Third edition

Transcription

1 Delivering better oral health: an evidence-based toolkit for prevention Third edition

2 Delivering better oral health: an evidence-based toolkit for prevention About Public Health England Public Health England s mission is to protect and improve the nation s health and to address inequalities through working with national and local government, the NHS, industry and the voluntary and community sector. PHE is an operationally autonomous executive agency of the Department of Health. Public Health England Waterloo Road Wellington House London SE1 8UG Tel: For queries relating to this document, please contact: jenny.godson@phe.gov.uk Crown Copyright 2014 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v2.0. To view this licence, visit OGL or psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Figures 4.1 and 4.2 reproduced from The Scientific Basis of Oral Health Education (7th edition), with kind permission of Dr R S Levine and BDJ Books. Published June 2014 PHE gateway number: This document is available in other formats on request. Please call or publications@phe.gov.uk

3 Delivering better oral health: an evidence-based toolkit for prevention Contents About Public Health England Foreword 1 Introduction to third edition 2 The prevention toolkit 4 Section 1 Summary guidance for primary dental care teams 6 Section 2 Principles of toothbrushing for oral health 17 Section 3 Increasing fluoride availability 19 Fluoridation of water and milk 19 Toothpaste list of current products by fluoride concentration level 22 Fluoride varnish 28 Prescribing high concentration fluoride toothpaste 30 Prescribing additional fluoride tablets and rinses 30 Section 4 Healthy eating advice 32 Dietary advice to prevent dental caries 32 General good dietary practice guidelines 34 Diet diary 38 Section 5 Sugar-free medicines 42 Section 6 Improving periodontal health 44 Section 7 Smoking and tobacco use 51 Section 8 Alcohol misuse and oral health 63 Section 9 Prevention of erosion 69 Section 10 Helping patients to change their behaviour 74 Section 11 Supporting references 79 Acknowledgements 99

4 Delivering better oral health: an evidence-based toolkit for prevention 1 Foreword It is well recognised that oral health has an important role in the general health and well being of individuals and it is of concern that significant inequalities in oral health exist across England. The risk factors for many general health conditions are common to those that affect oral health, namely smoking, alcohol misuse and a poor diet. It is therefore important that all clinical teams make every contact count and support patients to make healthier choices. By doing this not only will patients oral health benefit but their general health will be at lower risk as well. Clinical dental teams therefore have an important role in advising their patients about how they can make choices that improve and maintain both their dental and general health. Public Health England is pleased to provide this third edition of the prevention toolkit for clinical teams. Current evidence has been reviewed and used to revise and develop the previous edition. I am sure this key document will allow all patients to benefit from modern preventive treatments and improved methods of self-care. It should be used by the whole dental team to ensure that all patients have equity of access to improved preventive advice and care. Prof. Kevin Fenton, director of Health and Wellbeing Sue Gregory, head of dental public health Public Health England

5 2 Delivering better oral health: an evidence-based toolkit for prevention Introduction to third edition Publication of Delivering better oral health an evidence-based toolkit for prevention in 2007 led to a range of positive changes that have increased the likelihood of people in England benefiting from improved oral health. The guidance states the minimum concentrations of fluoride in toothpaste to control caries and prompted several manufacturers to reformulate their children s toothpaste to a more effective level for caries control. Coupled with clear advice about twice daily brushing, this is likely to have reduced caries activity among our very young children. Guidance regarding the important role of fluoride varnish as part of clinical activity to control caries has led to a large increase in the number of primary care teams applying this routinely and regularly to their child patients and to adults at higher risk. The simple item of advice that patients should spit out after brushing instead of rinsing away the fluoride in their toothpaste has been widely broadcast and should lead to lower caries levels among children, adolescents and adults. All of this is good news and large numbers of primary care teams have commented about how useful the toolkit has been to ensure that consistent advice is given as part of preventively orientated treatment plans. The document has also ensured that other health and social care partners are aware of the correct preventive messages and this has improved coherence between dental teams and other agencies. A further benefit has been the increased training of DCPs to support preventive activity in practices. This is to be encouraged and runs in alignment with the principles of the dental contract reform programme which is focussing dental services towards a more preventive approach. This toolkit is an enabling document which lists the evidence-informed messages which allows them to be given consistently. The toolkit also supported a new approach whereby all patients, regardless of perceived risk level, were given preventive advice and offered preventive treatment. This serves to establish new social norms for better home care and recognises the fact that not all new disease can be anticipated so all patients can benefit from advice and support. With 52% of adults and 70% of children contacting a dentist in every 24 month period the power of the messages that dental clinical teams can have is considerable. The toolkit has informed commissioners and allowed contracts to be developed which encourage preventive activity. It has also been useful in informing other health, education and social care work partners so that better daily care can be brought into a variety of settings. This third edition continues to support these positive effects and will be accompanied by versions which will help patients to better understand the preventive messages. The summary tables have been reviewed and revised, particularly the table referring to

6 Delivering better oral health: an evidence-based toolkit for prevention 3 periodontal disease. Where new evidence has emerged this has been assessed and the grade indicating the strength of evidence increased where appropriate. Additional tables have been provided to summarise advice about healthy eating, smoking and alcohol misuse. The sections providing more detail have also been improved and a section about behaviour change has been added. We would like to thank the members of the working group that have reviewed and revised material for this third edition and the wider organisations that contributed to it. We strongly commend this toolkit to you so that you may develop a preventive approach to your practise. Sue Gregory OBE Head of dental public health Jenny Godson Lead for oral health improvement Public Health England

7 4 Delivering better oral health: an evidence-based toolkit for prevention The prevention toolkit Many dental teams have asked for clear guidance about the advice they should give and the actions they should take to be sure they are doing the best for their patients in preventing disease. There is currently a drive for greater emphasis on prevention of ill-health and reduction of inequalities of health by the giving of advice, provision of support to change behaviour and application of evidence-informed actions. It is important that the whole dental team, as well as other healthcare workers, give consistent messages and that those messages are up to date and correct. Recent thinking suggests that all patients should be given the benefit of advice and support to change behaviour regarding their general and dental health, not just those thought to be at risk. This guide lists the advice and actions that should be provided for all patients to maintain good oral health. For those patients about whom there is greater concern (eg, those with medical conditions, those with evidence of active disease and those for whom the provision of reparative care is problematic) there is guidance about increasing the intensity of generally applied actions. A number of well-respected experts have come together to produce this document which aims to provide practical, evidencebased guidance to help clinical teams to promote oral health and prevent oral disease in their patients. It is intended for use throughout primary dental care. This toolkit is not the result of multiple systematic review processes, rather a pragmatic and progressive approach was taken towards the original collation of the available evidence and applied in revisions for each new edition. The steering group conferred with leaders in the field and established core messages and actions for which evidence had revealed a preventive benefit. Relevant papers were assessed for the detail and strength of evidence they revealed, then statements were refined to ensure the wording correctly reflected the conclusions derived. The published papers that gave the highest level of evidence available are provided as references to support each statement (and can be found in section 11). In many instances intelligence was drawn from a range of studies or reviews and statements were derived from the totality of the resulting evidence The information displayed in the model is supported by evidence of varying levels of strength. Where the evidence level is weak this does not mean that the intervention does not work but simply that the current evidence supporting it is not of the highest quality. Each piece of advice or suggested intervention is presented with an evidence grade. This represents the highest grade of evidence that currently exists for the advice or intervention listed in the model.

8 Delivering better oral health: an evidence-based toolkit for prevention 5 The grades of evidence given are as follows: Grade I II III IV V (Gray, 1997) Strength of evidence Strong evidence from at least one systematic review of multiple well-designed randomised control trial/s. Strong evidence from at least one properly designed randomised control trial of appropriate size. Evidence from well-designed trials without randomisation, single group pre-post, cohort, time series of matched case-control studies. Evidence from well-designed non-experimental studies from more than one centre or research group. Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees. For this new edition a symbol that indicates good practice has been added to statements for which specific evidence is not available but which make practical sense. This is shown as GP. There is an intention to re-classify the evidence in the next edition of the toolkit using the GRADE system.

9 Section 1 Summary guidance for primary care teams Prevention of caries in children age 0-6yrs Children aged up to 3 years Advice to be given EB Professional intervention EB Breast feeding provides the best nutrition for babies From six months of age infants should be introduced to drinking from a free-flow cup, and from age one year feeding from a bottle should be discouraged Sugar should not be added to weaning foods or drinks Parents/carers should brush or supervise toothbrushing As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste Brush last thing at night and on one other occasion Use fluoridated toothpaste containing no less than 1,000ppm fluoride It is good practice to use only a smear of toothpaste The frequency and amount of sugary food and drinks should be reduced I III V I I III I GP III, I Sugar-free medicines should be recommended III 6 Delivering better oral health: an evidence-based toolkit for prevention

10 All children aged 3-6 years Children aged 0-6 giving concern (eg, those likely to develop caries, those with special needs) Advice to be given EB Professional intervention EB Brush at least twice daily, with a fluoridated toothpaste Brush last thing at night and at least on one other occasion Brushing should be supervised by a parent/carer I Use fluoridated toothpaste containing more than 1,000 ppm fluoride It is good practice to use only a pea size amount Spit out after brushing and do not rinse, to maintain fluoride concentration levels The frequency and amount of sugary food and drinks should be reduced I III I GP III III, I Sugar-free medicines should be recommended III All advice as above plus: Use fluoridated toothpaste containing 1,350-1,500ppm fluoride It is good practice to use only a smear or pea size amount Where medication is given frequently or long term request that it is sugar free, or used to minimise cariogenic effects I GP GP Apply fluoride varnish to teeth two times a year (2.2% NaF-) Apply fluoride varnish to teeth two or more times a year (2.2% NaF-) Reduce recall interval Investigate diet and assist adoption of good dietary practice in line with the eatwell plate Where medication is given frequently or long term, liaise with medical practitioner to request it is sugar free, or used to minimise cariogenic effects I I V I GP Delivering better oral health: an evidence-based toolkit for prevention 7

11 Prevention of caries in children aged from 7 years and young adults All patients Those giving concern to their dentist (eg, those with obvious current active caries, those with ortho appliances, dry mouth, other predisposing factors, those with special needs) Advice EB Professional intervention EB Brush at least twice daily, with a fluoridated toothpaste Brush last thing at night and at least on one other occasion Use fluoridated toothpaste (1,350-1,500ppm fluoride) Spit out after brushing and do not rinse, to maintain fluoride concentration levels The frequency and amount of sugary food and drinks should be reduced All the above, plus: Use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing I III, I I III III, I I Apply fluoride varnish to teeth two times a year (2.2% NaF-) Fissure seal permanent molars with resin sealant I Apply fluoride varnish to teeth two or more times a year (2.2% NaF-) For those 8 years upwards with active caries prescribe daily fluoride rinse For those 10+ years with active caries prescribe 2800 ppm fluoride toothpaste For those 16+ years with active disease prescribe either 2,800ppm or 5,000ppm fluoride toothpaste Investigate diet and assist to adopt good dietary practice in line with the eatwell plate I I I I I I 8 Delivering better oral health: an evidence-based toolkit for prevention

12 Prevention of caries in adults All adult patients Those giving concern to their dentist (eg. with obvious current active caries, dry mouth, other predisposing factors, those with special needs Advice EB Professional intervention EB Brush at least twice daily, with a fluoridated toothpaste Brush last thing at night and at least on one other occasion Use fluoridated toothpaste with at least 1350ppm fluoride Spit out after brushing and do not rinse, to maintain fluoride concentration The frequency and amount of sugary food and drinks should be reduced All the above, plus: Use a fluoride mouthrinse daily (0.05% NaF-) at a different time to brushing I III, I I III III, I I Apply fluoride varnish to teeth twice yearly (2.2% NaF-) For those with active coronal or root caries prescribe daily fluoride rinse For those with obvious active coronal or root caries prescribe 2,800 or 5,000ppm fluoride toothpaste Investigate diet and assist to adopt good dietary practice in line with the eatwell plate I I I I Delivering better oral health: an evidence-based toolkit for prevention 9

13 Prevention of periodontal disease to be used in addition to caries prevention All adults and children Advice to be given EB Professional intervention EB Self-care plaque removal Remove plaque effectively using methods shown by the dental team This will prevent gingivitis and reduces the risk of periodontal disease Daily, effective plaque removal is more important to periodontal health than tooth scaling and polishing by the clinical team Toothbrushing and toothpaste Brush gum line AND each tooth twice daily (before bed and at least on one other occasion). For further information regarding toothpastes and periodontal health see section 6.1 Use either Manual or powered toothbrush I Small toothbrush head, medium texture V V III III V Advise best methods of plaque removal to prevent gingivitis, achieve lowest risk of periodontitis and tooth loss. Use behaviour change methods with oral hygiene instruction Correct factors which impede effective plaque control including; supra- and subgingival calculus, open margins and restoration overhangs and contours which prevent effective plaque removal With extensive inflammation start with toothbrushing advice, followed by interdental plaque control Assess patient s/parent/carer s preferences for plaque control Decide on manual or powered toothbrush Demonstrate methods and types of brushesassess plaque removal abilities and confidence with brush Patient sets target for toothbrushing for next visit III I GP GP V 10 Delivering better oral health: an evidence-based toolkit for prevention

14 All adults and ages Advice to be given EB Professional intervention EB Interdental plaque control Clean daily between the teeth to below the gum line before toothbrushing, For small spaces between teeth: use dental floss or tape For larger spaces: use interdental or single-tufted brushes Around orthodontic appliances and bridges: use kit suggested by the dental professional GP V V V Assess patient s preferences for interdental plaque control Decide on appropriate interdental kit Demonstrate methods and types of kit Assess plaque removal abilities and confidence with kit Patient sets target for interdental plaque control V Risk factor control Tobacco (all adults and adolescents) Diabetes Do not smoke Smoking increases the risk of periodontal disease, reduces benefits of treatment and increases the chance of losing teeth. Patients with diabetes should try to maintain good diabetes control as they are At greater risk of developing serious periodontal disease Less likely to benefit from periodontal treatment if the diabetes is not well controlled III V III V Ask, Advise, Act: take a history of tobacco use, give brief advice to users to quit and sign post to local stop smoking service (see tobacco table for more detail) For patients with diabetes: Explain risk related to diabetes GP I Delivering better oral health: an evidence-based toolkit for prevention 11

15 Medications Advice to be given EB Professional intervention EB Some medications can affect gingival health V For patients who use medications that cause dry mouth or gingival enlargement Prevention of peri-implant disease All adults with dental implants Dental implants require the same level of oral hygiene and maintenance as natural teeth Clean both between and around implants carefully with interdental kit and toothbrushes Attend for regular checks of the health of gum and bone around implants V V V Explain oral health findings and risk related to medication Assess and discuss clinical management (see section 6) Advise best methods for self-care plaque control, both toothbrushing and interdental cleaning GP GP V 12 Delivering better oral health: an evidence-based toolkit for prevention

16 Prevention of oral cancer Risk level Advice EB Professional intervention EB All adolescents and adults Do not smoke III Ask, Advise, Act tobacco use very brief advice I Do not use smokeless tobacco (eg, paan, chewing tobacco, gutkha) Reduce alcohol consumption to moderate (recommended) levels Increase intake of non-starchy vegetables and fruit I I III Take a history of tobacco use, give brief advice to users and signpost to local stop smoking service Ask, Advise, Act alcohol very brief advice Establish if the patient is drinking above low risk (recommended) levels. If appropriate signpost to GP or local alcohol misuse support services if available See tobacco and alcohol tables I I Delivering better oral health: an evidence-based toolkit for prevention 13

17 Evidence-based advice and professional intervention about smoking and other tobacco use All adolescents and adults Advice EB Professional intervention EB Tobacco use, both smoking and chewing tobacco seriously affects general and oral health. The most significant effect on the mouth is oral cancers and pre-cancers. III Ask, Advise, Act: take a history of tobacco use, give brief advice to users and signpost to local stop smoking service Do not smoke or use shisha pipes I Ask establish and record smoking status Do not use smokeless tobacco (eg, paan, chewing tobacco, gutkha) If the patient is not ready or willing to stop they may wish to consider reducing how much they smoke using a licensed nicotine-containing product to help reduce smoking. The health benefits to reducing are unclear but those who use these will be more likely to stop smoking in the future. I V Advise advise on benefits of stopping and that evidence shows the best way is with a combination of support and treatment Act offer help referring to local stop smoking services I 14 Delivering better oral health: an evidence-based toolkit for prevention

18 Evidence-based advice and professional intervention about alcohol and oral health All adolescents and adults Advice EB Professional intervention EB Drinking alcohol above recommended levels adversely affects general and oral health with the most significant oral health impact being the increased risk of oral cancer. Reduce alcohol consumption to low risk (recommended) levels. Recommended levels (May 2014): Men should not regularly consume more than 3 to 4 units per day Women should not regularly consume more than 2 to 3 units per day All drinkers should avoid alcohol for 2 days following a heavy drinking session to allow the body to recover Pregnant women or women trying to conceive should avoid drinking alcohol but if they choose to drink they should limit this to no more than 1 to 2 units once or twice a week and avoid getting drunk IV I For all patients: Ask establish and record if the patient is drinking above low risk (recommended) levels Advise offer brief advice to those drinking above recommended levels Act refer or signpost high risk drinkers to their GP or local alcohol support services I Delivering better oral health: an evidence-based toolkit for prevention 15

19 Evidence-based advice and professional intervention about healthier eating All ages Advice to be given EB Professional intervention EB The frequency and amount of consumption of sugars should be reduced Avoid sugar containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost Prevention of erosion/toothwear III, I To aid dietary modification advice consider using a diet diary over 3 days, one weekend day and 2 weekdays No table could be provided as the evidence to support interventions to prevent toothwear is currently limited. Some tooth wear is a natural part of ageing; thus at present evidence-based population advice on tooth wear, and particularly erosion, cannot be substantiated. Evidence from studies to support preventive interventions for individuals with pathological wear is limited, but growing. Much of the available evidence to date relates to associations and is largely limited to epidemiology, laboratory and in situ studies; thus, further research in this field is recommended. The later chapter about erosion and toothwear describes possible causes and an overview of methods of management, which includes advice about prevention of toothwear according to the need of individual patients. III GP 16 Delivering better oral health: an evidence-based toolkit for prevention

20 Delivering better oral health: an evidence-based toolkit for prevention 17 Section 2 Principles of toothbrushing for oral health The major dental conditions of caries and periodontal disease can both be reduced by regular toothbrushing with fluoride toothpaste. To control caries it is the fluoride in toothpaste which is the important element of toothbrushing, as fluoride serves to prevent, control and arrest caries. Higher concentration of fluoride in toothpaste leads to better caries control. To control gum disease the physical removal of plaque is the important element of toothbrushing as it reduces the inflammatory response of the gingivae and its sequelae. Some toothpastes contain ingredients which also reduce plaque, gingivitis and bleeding gums. There is evidence to suggest that the preventive action of toothbrushing can be maximised if the following principles are followed: brushing should start as soon as the first primary tooth erupts brushing should occur twice daily as a minimum clean teeth last thing at night before bed and at least one other time each day children under three years should use a toothpaste containing no less than 1,000 ppm fluoride children under three years should use no more than a smear of toothpaste (a thin film of paste covering less than threequarters of the brush) and must not be permitted to eat or lick toothpaste from the tube family fluoride toothpaste (1,350-1,500 parts per million fluoride ppmf) is indicated for maximum caries control for all children except those who cannot be prevented from eating toothpaste. Advice must be given about adult supervision and the small amounts to be used

21 18 Delivering better oral health: an evidence-based toolkit for prevention children between three and six years should use no more than a pea-sized amount of toothpaste brushing is more effective with a smallheaded toothbrush with medium-texture bristles (ISO 20126: 2012), (V) While there is evidence that some powered toothbrushes (with a rotation, oscillation action) can be more effective for plaque control than manual tooth brushes, probably more important is that the brush, manual or powered, is used effectively twice daily. Thorough cleaning may take at least two minutes. children need to be helped or supervised by an adult when brushing until at least seven years of age and must not be permitted to eat or lick toothpaste from the tube rinsing with lots of water after brushing should be discouraged spitting out excess toothpaste is preferable rinsing with water, mouthwashes or mouth rinses (including fluoride rinses) immediately after toothbrushing will wash away the concentrated fluoride in the remaining toothpaste, thus diluting it and reducing its preventive effects. For this reason rinsing after toothbrushing should be discouraged the patient s existing method of brushing may need to be modified to maximise plaque removal, emphasising the need to systematically clean all tooth surfaces. No particular technique has been shown to be better than another disclosing tablets can help to indicate areas that are being missed

22 Delivering better oral health: an evidence-based toolkit for prevention 19 Section 3 Increasing fluoride availability Fluorides are widely found in nature and in foods such as tea, fish, beer and in some natural water supplies. The link between fluoride in public water supplies and reduced levels of caries was first documented early in the last century. Since then fluoride has become more widely available, most notably in toothpaste and is widely recognised as having improved oral health in the UK. There is abundant evidence that increasing fluoride availability to individuals and communities is effective at reducing caries levels. This can be achieved by a range of methods but similar principles apply to all. Fluoride works topically in the main and is most effective if it is available multiple times during the day. Higher concentrations of fluoride provide better caries prevention effects and vehicles which are parts of normal life are more likely to be effective and avoid increasing inequalities. When vehicles and concentrations of fluoride are considered for caries control the only risk to health is fluorosis, and this is only the case if young children receive excess levels (see section 2). A balance has to be achieved whereby the most benefit can be gained from this naturally occurring substance, while at the same time avoiding the risk of fluorosis. Water fluoridation Currently approximately 10% of England s population, or about six million people, benefit from a water supply where the fluoride content, either naturally or artificially, is at the optimum level for dental health. In terms of population coverage, the West Midlands is the most extensively fluoridated area, followed by parts of the North East of England. Consumers seeking information on fluoride levels in their water can obtain this from their water supplier. Many water companies having an online function to allow consumers to check this. This is particularly important where additional fluoride is being considered for young children. Information on how fluoride availability can be increased on an individual basis to improve oral health now follows. Milk fluoridation There are a few schemes in England which supply children with fluoridated milk at school. They are provided in areas which are not fluoridated and where levels of caries are high. Children should not take part if they have fluoride tablets or fluoride rinse on a daily basis. Fluoride toothpaste Strong evidence shows that toothpastes containing higher concentrations of fluoride are more effective at controlling caries. It is clear that low fluoride toothpastes (those containing less than 1,000ppmF-) are ineffective at controlling caries.

23 20 Delivering better oral health: an evidence-based toolkit for prevention A Cochrane systematic review of evidence stated that There should be a balanced consideration between the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis (Wong, 2010). This review focusses on mild or questionable fluorosis and did not distinguish between this and the more severe forms. Mild fluorosis is not readily apparent to the affected individual or casual observer and often requires a trained specialist to detect it. The review concluded that the evidence about the risk of fluorosis from starting the use of fluoride toothpaste in children under 12 months of age was weak, and for starting between the age of 12 and 24 months was equivocal. It also stated that where the risk of fluorosis is of particular concern, the fluoride level of toothpaste for young children is recommended to be lower than 1,000ppm. However, for children considered to be at high risk of tooth decay by their dentist, the benefit to health of preventing decay may outweigh the risk of fluorosis. In such circumstances, careful brushing by parents/ carers with toothpastes containing higher levels of fluoride would be beneficial. The risk of fluorosis from ingesting too much fluoride are linked much more to the amount of toothpaste that is used, than to the concentration. Risks of aesthetically challenging fluorosis to permanent incisors are relevant only to ingestion of fluoride by those under three years old. Calcification of the crowns of these teeth is complete by 30 months. Risks of aesthetically challenging fluorosis to premolars are only relevant to those aged under six years as calcification of the crowns of these teeth is complete by this age. A research study investigated the concentration and amount of toothpaste used by children aged one to two years. This showed that the ingestion of fluoride among children who used a large amount of paste could be as much as twenty times higher than that for children who used only a small amount. In contrast there was only a four fold difference in the amount of fluoride ingested between those who used a low fluoride toothpaste and those using one containing 1,450ppm. See figure 3.1 mg fluoride ingested Fluoride concentration Small amount placed on brush Large amount placed on brush 1,450ppm 0.05mg 20 fold 1.02mg 440ppm 4 fold 0.02mg 0.33mg Source: Bentley, Ellwood and Davies, 1999 Figure 3.1 The impact of concentration and amount of toothpaste used on fluoride ingested

24 Delivering better oral health: an evidence-based toolkit for prevention 21 Putting these pieces of evidence together shows that the best combination is to use higher concentration toothpaste in very small quantities for children aged six years and below. For this reason parents should be shown how small an amount to use and they should ensure their children do not eat or lick the toothpaste. Children aged under three years should use only a smear of toothpaste. Children aged three to six years should use only a pea-sized blob of toothpaste.

25 22 Delivering better oral health: an evidence-based toolkit for prevention Types of over-the-counter toothpastes by fluoride concentration level This table is provided for information only and should NOT be seen as an endorsement of any particular brand by PHE. Efforts have been made to make the list as comprehensive as possible but it may not represent a complete list of all brands of toothpaste available in the UK and was correct at the time of press, March This table cannot provide information about levels of fluoride in brands bought from such places as single price stores, markets, websites and car boot sales, which may be special imports or, on occasion, counterfeit, and not contain known levels of fluoride. Such toothpaste may not offer protection against decay. Read the label to look for the parts per million of fluoride (ppmf-) in the toothpaste. Higher concentration fluoride gives better protection against decay Toothpastes containing 1,000-1,500ppmF- Brand ALDI Dentitex all types ASDA Protect Big Teeth 6+, Total care, Extreme Fresh, Whitening, Sensitive Smart Price Aquafresh Active Cavity Protection, Fresh Breath Active Whitening Fluoride Big Teeth 12 Hour Protection Extreme Clean, Whitening Fresh Minty HD White Illuminating Mint, Tingling Mint Iso-Active fresh mint fluoride, Clean and whiten Little Teeth Mild Minty Milk Teeth 3-5 years Multi-action whitening Multi Active Fluoride Triple Protection, Whitening

26 Delivering better oral health: an evidence-based toolkit for prevention 23 Toothpastes containing 1,000-1,500ppmF- Brand Arm and Hammer Advance White, Whitening, Whitening Sensitive Brilliant Sparkle, Enamel Pro Repair Sensitive, Extra White, Original Coolmint Beverley Hills Formula Total enamel sensitive expert Perfect White Biotene fluoride Boots Smile Fresh Stripe, Total care, Whitening, Sensitive Expert Sensitive Whitening, Enamel Protection, weekly clean Expert orthodontic Smile Kids 6+ Corsodyl Extra Fresh Original, Whitening Colgate 2 in 1 Whitening, icy Blast Advanced White, Whitening, Whitening Go Pure Fresh Minty Gel Cavity Protection Cool Stripe Deep Clean Whitening Sensitive Enamel Protect Cavity Protection Great Regular Max Beads Blue, Max Fresh Blue Maxwhite, One, One Active, One Luminous, One Optic, Shine Sensitive Enamel Protect, Sensitive and Whitening, multi-protection, Plus Whitening, Pro-relief, Pro-relief and whitening, pro-relief Enamel repair, Pro-relief Multi-protect Kids 4-6 Kids 6+ Total* Advanced, Clean*, Freshening*, Pro-Gum Health*, Pro-Gum Health Whitening*, Sensitive*, Whitening*, Interdental* Triple Action Whitening and Fresh breath Co-operative Freshmint Whitening and totalcare, Sensitive and totalcare

27 24 Delivering better oral health: an evidence-based toolkit for prevention Brand Fluoridine Janina Ultra White Extra strength, White Sensitive Kingfisher Mint with Fluoride, Fennel with Fluoride Kokomo Peppa Pig Macleans Fresh Mint Ice Whitening Toothpaste Total Health and Whitening White n Shine Whitening, Whitening Fluoride Mentadent Mentadent P with zinc citrate, Mentadent SR Oral B Stages Bubble gum Toothpastes containing 1,000-1,500ppmF- 3D White Enamel Protect, White Brilliance, White Luxe Healthy Shine Complete Extra Fresh, Extra White, mouthwash and whitening Pro Expert All Around Protection Clean Mint, All Around, Enamel Shield, Premium Gum Protection, Sensitive + Gentle Whitening, Whitening Pearl Drops Pro White, Instant White, Restore White, Ultimate White Everyday white Sainsbury s own Basics Extracare Fresh and Whitening, Sensitive and Whitening Freshmint Gentle Whitening Sensitive, Sensitive Enamel Whitening Kids Toothpaste 3-6

28 Delivering better oral health: an evidence-based toolkit for prevention 25 Toothpastes containing 1,000-1,500ppmF- Brand Sensodyne Complete Protection, Extra Fresh Daily Care Extra Fresh Gentle Whitening Gum Protection Iso Active Whitening Mint Pronamel Daily Toothpaste. Daily Fluoride Children 6 12 years. Extra Freshness, gentle whitening Rapid Relief Mint Repair & Protect Extra Fresh, Whitening Total Care, gentle whitening Smith Kline Beecham Corsodyl Daily Extra Paste, Daily Whitening Superdrug Procare Tesco s own Everyday Value Kids Strawberry Freshmint Sensitive Whitening Steps Toothpaste 0-2 Steps Toothpaste 3-, 6+ Pro-formula Daily protection sensitive. All day protection complete, sensitive, complete whitening, Daily protection enamel protect, Extreme whitening, freshmint Tom s of Maine Fennel and Spearmint Wilkinsons Wilko whitening, Freshmint Fresh Wisdom Xtra clean Zohar kosher toothpaste

29 26 Delivering better oral health: an evidence-based toolkit for prevention Toothpastes containing exactly 1,000ppmF- Brand ASDA Protect 0-3 Milk Teeth Aquafresh Milk Teeth 0-2 years Beverley Hills Formula Total protection whitening Sensitive whitening Dentist s choice Boots Essentials White Glo 2 in 1 White Glo Coffee & tea formula White Glo Extra strength Smile Kids 2-6 Clinomyn Smoker s Colgate Kids 0-3 Dr Fresh Thomas the Tank Engine Kokomo Hello Kitty Sainsbury s own Kids Toothpaste 0-3 Tom s of Maine Fennel and Spearmint Ultradex was Retardex Low Abrasion White Glo Recalcifying & whitening Wilkinsons Wilko Everyday value

30 Delivering better oral health: an evidence-based toolkit for prevention 27 Toothpastes containing less than 1,000ppmF- (low concentration) limited/no protection against decay Brand Blanx Advance whitening Intensive Stain Removal Sensitive White Shock Boots Smile Kids 0-2 Co-operative LIDL Dentalux for kids 0-6 Oral B Stages Berry Bubble Toothpastes containing no fluoride Brand Beverley Hills Formula Natural whitening Boots Smile Non Fluoride Elgydium Eucryl Powder Euthymol Kingfisher Fennel fluoride free Baking soda fluoride free Mint with lemon fluoride free Aloe vera, Tea Tree, Mint fluoride free Optima AloeDent triple action AloeDent Bambini Oral B Rembrandt Plus Fresh Mint

31 28 Delivering better oral health: an evidence-based toolkit for prevention Toothpastes containing no fluoride Brand Sensodyne Original Tom s of Maine Many types of fluoride free *Toothpastes containing triclosan with co-polymer Fluoride varnish Fluoride varnish is one of the best options for increasing the availability of topical fluoride, regardless of the levels of fluoride in the water supply. High quality evidence of the caries-preventive effectiveness of fluoride varnish in both permanent and primary dentitions is available and has been updated recently. A number of systematic reviews conclude that applications two or more times a year produce a mean reduction in caries increment of 37% in the primary dentition and 43% in the permanent. The evidence supports the view that varnish application can also arrest existing lesions on the smooth surfaces of primary teeth and roots of permanent teeth. Much of the evidence of effectiveness is derived from studies which have used sodium fluoride 22,600ppm varnish for application. Fluoride varnish for use as a topical treatment has a number of practical advantages. It is well accepted and considered to be safe. Further, the application of fluoride varnish is simple and requires minimal training. While a thorough prophylaxis is not essential prior to application, removal of gross plaque is advised. Dental nurses can be trained to apply fluoride varnish to the prescription of a dentist and this use of skill mix can assist a practice to become more preventively orientated. Primary care commissioning provides guidance about the circumstances under which dental nurses can carry this out and the minimum requirements for training courses, which should include a significant amount of content about giving preventive advice. Care should be used to ensure that only a small quantity of varnish is applied to teeth, particularly for young children. Teeth should be dried with cotton wool rolls or a triple syringe. The varnish should be carefully applied with a microbrush to pits, fissures and approximal surfaces of primary and permanent teeth and to any carious lesions. The patient should be advised to avoid eating, drinking or rinsing for 30 minutes after application and eat only soft foods in the following four hours. Brushing can

32 Delivering better oral health: an evidence-based toolkit for prevention 29 recommence on the day following application of fluoride varnish The use of Duraphat is contraindicated in patients with ulcerative gingivitis and stomatitis. There is a very small risk of allergy to one component of Duraphat (colophony), so for children who have a history of allergic episodes requiring hospital admission, including asthma, varnish application is contraindicated. Other brands of varnish may have different constituents. Some fluoride varnishes contain alcohol but it has been agreed on the authority of the West Midlands Shari ah Council that they are suitable for use by Muslims as they are being used as a medicament and are not an intoxicant, and are used in small amounts well below that which would intoxicate and they are not being used for reasons of vanity. Clinicians should be aware that there are many fluoride varnishes on the market. They may not be licensed for caries control, although they may have similar formulations, and this should be taken into consideration with respect to prescriber s responsibilities.

33 30 Delivering better oral health: an evidence-based toolkit for prevention Prescribing high concentration fluoride toothpaste Sodium fluoride 2,800ppm toothpaste Indications: high caries risk patients aged ten years and over, those with caries present, orthodontic appliances, a highly cariogenic diet or medication. Sodium fluoride 5,000ppm toothpaste Indications: patients aged 16 years and over with high caries risk, present or potential for root caries, dry mouth, orthodontic appliances, overdentures, those with highly cariogenic diet or medication. Use of additional fluoride Fluoride tablets and drops It is recognised that the use of fluoride tablets and drops requires compliance by families and this may include under and over-use. There is a risk of fluorosis if children aged under six years take more than the advised dose. With this in mind, other sources of fluoride may be preferable and therefore be considered first. Twice daily brushing with fluoride toothpaste containing at least 1,000ppm fluoride, or higher for those at risk, is a higher priority step, and is likely to bring lifelong benefits. A recent systematic review of fluoride tablets, drops, lozenges and chewing gums concluded that the evidence of the effect of these additional sources of fluoride was unclear on deciduous teeth. Fluoride rinses These can be prescribed for patients aged eight years and above, for daily use, in addition to twice daily brushing with toothpaste containing at least 1,350ppm fluoride. Rinses require patient compliance and should be used at a different time to toothbrushing to maximise the topical effect, which relates to frequency of availability. Rinsing, even with a fluoride rinse immediately after brushing will reduce the beneficial

34 Delivering better oral health: an evidence-based toolkit for prevention 31 effects of fluoride toothpaste. Fluoride in toothpaste (1,000-1,500ppm) is at a higher concentration compared with fluoride rinses (225ppm) and so is more effective if retained in the mouth, rather than being diluted or washed away by rinses. References Wong MCM, Glenny AM, Tsang BWK, Lo ECM, Worthington HV, Marinho VCC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Database of Reviews 2010, Issue 1. Art. No.: CD DOI: / CD pub2. Tubert-Jeannin S, Auclair C, Amsallem E, Tramini P, Gerbaud L, Ruffieux C, et al. Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children. Cochrane Database of Reviews 2011, Issue 12. Art. No.: CD DOI: / CD pub2. Bentley EM, Ellwood RP, Davies RM, (1999). Fluoride ingestion from toothpaste by young children. Br Dent J. 8;186(9): Primary Care Commissioning, (2009). The use of fluoride varnish by dental nurses to control caries. articles/attachments/the_use_of_fluoride_ varnish.pdf.

35 32 Delivering better oral health: an evidence-based toolkit for prevention Section 4 Healthier eating advice Healthier eating advice should routinely be given to patients to promote good oral and general health. Key dietary messages to prevent dental caries are summarised below. The main message is to reduce both the amount and frequency of consuming foods and drinks that have added sugar. Added sugar is defined as sugars or syrups added to foods and drinks by the manufacturer, cook or consumer, plus sugars present in honey, syrups, fruit juices and fruit concentrates. It does not include sugars found in whole fresh fruit and vegetables and those naturally present in milk and milk products. Dietary advice to prevent dental caries Consensus recommendations advocate the following to prevent caries: the amount and frequency of consumption of sugars should be reduced avoid sugar-containing foods and drinks at bedtime added sugars should provide less than 10% of total energy in the diet or 60g per person per day whichever is the lesser. Note that for young children this will be around 30g per day (one teaspoon of sugar equates to approximately 5-6g) The World Health Organisation (WHO) has revised its guidelines on sugar intake for adults and children. They contain a strong recommendation that in adults and children the intake of free sugars should not exceed 10% of total energy and a conditional recommendation of a further reduction to below 5% of total energy. The Scientific Advisory Committee on Nutrition, a committee of independent experts who advise the government on nutrition issues, are currently reviewing the evidence on sugars and other carbohydrates in diet as part of their report Carbohydrates and health. This will include evaluating the evidence on oral health as well as other health outcomes. A draft report is expected to be published for consultation on 26 June The healthier eating guidance in Delivering better oral health will be updated in the light of this publication. Most added sugars in the diet are contained in processed and manufactured foods and drinks. Consumers should check labels carefully. Potentially cariogenic foods and drinks include: sugared soft drinks sugar and chocolate confectionery cakes and biscuits buns, pastries, fruit pies sponge puddings and other puddings table sugar breakfast cereals jams, preserves, honey

36 Delivering better oral health: an evidence-based toolkit for prevention 33 ice cream and sorbets fruit in syrup or canned in juice fresh fruit juices (ONE 150ml glass of fresh fruit juice can count towards five a day ) sugared, milk-based beverages sugar-containing alcoholic drinks dried fruits syrups and sweet sauces It is important to recognise that honey, fruit smoothies, fresh fruit juice and dried fruit all contain cariogenic sugars. Frequency of consumption of foods and drinks containing sugar Stephan s curve illustrates why the frequency of intake of sugars is particularly relevant for caries. Figure 4.1 below illustrates how demineralisation of tooth surfaces occurs after a sugar intake and the subsequent drop in ph that takes place in the mouth as oral bacteria convert sugar to acid. This process stops as the buffering action of saliva takes place and is more rapid in the presence of fluoride. When sugar intakes are spaced some hours apart there is a good opportunity for remineralisation, which is also more effective in the presence of fluoride. Saliva production is stimulated at mealtimes and much reduced during sleep. Figure 4.1 Illustration of effects of infrequent sugar intakes.

37 34 Delivering better oral health: an evidence-based toolkit for prevention Figure 4.2 Illustration of effects of frequent sugar intakes. The impact of frequent sugar intakes are illustrated in Stephan s curve in figure 4.2. In this case sugar intakes are experienced on many occasions during the day so demineralisation occurs more often and the time between drops in ph is not long enough for effective remineralisation to take place. General good dietary practice guidelines Key facts for eating well Below are some of the main healthy eating messages aimed at helping people make healthier dietary choices. The two most important elements of a healthy diet are: eating the right amount of food relative to how active a person is to be a healthy weight eating a range of foods in line with the eatwell plate The eatwell plate is a key policy tool that defines the government s recommendations on a healthy diet. It makes healthy eating easier to understand by giving a visual representation of the types and proportions of foods needed for a healthy, balanced diet. The eatwell plate shows the types and proportions of the main food groups that we should eat as part of a healthy, balanced diet: plenty of fruit and vegetables (at least five portions of a variety every day) plenty of starchy foods, such as bread, rice, potatoes, and pasta, choosing wholegrain varieties and potatoes with their skins on whenever possible some milk and dairy foods some meat, fish, eggs, beans and other non-dairy sources of protein Foods and drinks high in fat, sugar and/or salt should be consumed infrequently and in small amounts.

38 Delivering better oral health: an evidence-based toolkit for prevention 35 Key messages for a healthier diet Base meals on starchy foods Try to choose wholegrain varieties, and potatoes with their skins on, whenever possible as wholegrain foods and the skins on potatoes contain more fibre and other nutrients than white or refined starchy foods. We also digest wholegrain foods more slowly so they can help make us feel full for longer. Eat lots of fruit and vegetables At least five portions of a variety of fruit and vegetables should be eaten every day; different fruit and vegetables contain different combinations of fibre, vitamins and other nutrients. Eating more fruit and vegetables may help to reduce the risk of the two main killers in this country heart disease and cancer. Most people know they should be doing this but still don t. Eating five plus portions a day can be easy. A portion of fruit and vegetables is 80g. Eat more fish Two portions of fish, including a portion of oily fish, eg salmon, trout, sardines, mackerel, sardines, pilchards, herrings, kipper, eels, whitebait and fresh tuna, should be eaten each week. The choice can be from fresh, frozen or canned but canned and smoked fish can be high in salt. The fish count as oily fish when they re canned, fresh or frozen. However, fresh tuna is an oily fish but canned tuna doesn t count as oily. This is because when it s canned these fats are reduced to levels similar to white fish. So, canned tuna is a healthy choice for most people, but it doesn t have the same benefits as eating oily fish.

39 36 Delivering better oral health: an evidence-based toolkit for prevention Cut down on saturated fat To stay healthy we need some fat in our diets. There are two main types of fat: saturated fat having too much can increase the amount of cholesterol in the blood, which increases the chance of developing heart disease. Foods containing this include: fatty meat, pâté, meat pies, sausages, hard cheese, butter, lard, full fat milk, and biscuits, cakes and pastry unsaturated fat having unsaturated fat instead of saturated fat does not increase blood cholesterol levels. Good sources include: vegetable oils (such as sunflower, rapeseed and olive oil), oily fish, avocados, nuts and seeds However, it is important not to increase the amount of total fat consumed because eating too much will increase energy intake and if greater than energy used may lead to weight gain. Cut down on the amount and frequency of sugary food intake As stated at the beginning of this section, consensus recommendations in order to reduce dental caries advocate reducing the amount and frequency of foods and drinks containing added sugars. Increased intake of sugars can lead to increased energy intake and if greater than expenditure to weight gain. Eat less salt no more than 6g a day Three-quarters (75%) of the salt we eat comes from processed food, such as some breakfast cereals, soups, sauces, bread, biscuits and ready meals. Eating too much salt can raise blood pressure. People with high blood pressure are three times more likely to develop heart disease or have a stroke than people with normal blood pressure. Drink plenty of water We should be drinking about six to eight glasses (1.2lts) of water, or other fluids, every day to stop us getting dehydrated. There are specific dietary recommendations for infants and young children: aspx#close and click on the babies and toddlers tab Source of key messages: Department of Health, Change4Life: Changing the diet The diet modification approach should be used in conjunction with actions to increase fluoride availability (as outlined in section 1). However, lowering the amount and frequency of sugars consumed will have wider health benefits, preventing weight gain and obesity which in turn will reducing the risk of heart disease, type 2 diabetes and some cancers. When giving dietary advice to reduce consumption of sugars it is essential to assess the overall pattern of eating to establish the following information: the number of intakes of food and drinks per day the number of intakes that contain added sugars and how many were consumed between normal mealtimes

40 Delivering better oral health: an evidence-based toolkit for prevention 37 whether any intakes containing sugars were taken within one hour of bedtime (when the caries protective effects of saliva are reduced) In some cases it can be helpful to use a diet diary. An example of one type of diary is provided in appendix 4.1

41 38 Delivering better oral health: an evidence-based toolkit for prevention Appendix 4.1 Example of a diet diary Instructions on completing a diet diary Please write down everything you (or your child if completing on their behalf) eats or drinks and the time during the day when consumed this will help us to advise you on how best to improve your diet. Choose one weekend day and two others. Please bring the diet diary with you to the next appointment. Here is an example to show you how the diary should be filled in: Record of food and drinks eaten and drink by. TIME DAY 1 Friday cup of Tropicana orange juice Breakfast Weetabix + sugar + milk 2 rounds of toast with butter and Marmite 8.30, on the way to school 10.30, school break time 2 Hobnobs Can of Sprite Muesli health bar pm Ham sandwich, cheese and onion crisps, diet coke 3.30 pm Banana 6 pm Roast chicken, potatoes peas, gravy. Rhubarb crumble and custard 7 pm Packet of Malteasers 8 pm bedtime Hot chocolate drink and Hobnob

42 Delivering better oral health: an evidence-based toolkit for prevention 39 Record of food and drinks eaten and drink by. TIME DAY 1

43 40 Delivering better oral health: an evidence-based toolkit for prevention Record of food and drinks eaten and drink by. TIME DAY 2

44 Delivering better oral health: an evidence-based toolkit for prevention 41 Record of food and drinks eaten and drink by. TIME DAY 3

45 42 Delivering better oral health: an evidence-based toolkit for prevention Section 5 Sugar-free medicines Identifying sugar-free medicines Products that do not contain fructose, glucose or sucrose are listed as sugar free. Preparations containing hydrogenated glucose syrup, lycasin, maltitol, sorbitol or xylitol are also listed as sugar free, since there is evidence they are non-cariogenic. Artificial sweeteners are also listed as sugar free. Patients that could be on liquid medications include chronically ill children, frail elderly and adults with special needs. Children with chronic conditions such as epilepsy could require liquid medication for a long time. Frequent liquid medications could also be taken for a number of reasons including analgesia, infections and coughs and colds. Information from the National Pharmacy Association leaflet Sugar in medicines was adapted for use in previous editions of Delivering better oral health. The leaflet was last reviewed in 2006 and much of the information in the leaflet is now out of date. NHS Business Services Authority provided data on British National Formulary (BNF) prescribing data at presentation for January to December From this list the top 10 most prescribed medication as liquids, solutions and suspensions are shown table 5.1. Table 5.1 List of ten most prescribed liquids and suspensions during 2013* BNF name Lactulose_Soln 3.1g-3.7g/5ml 3,785,249 Ensure Plus_Milkshake Style Liq(10 Flav) 1,589,278 Amoxicillin_Oral Susp 125mg/5ml S/F 1,320,513 Fortisip Bottle_Liq (8 Flav) 1,161,414 Morph Sulf_Oral Soln 10mg/5ml 778,880 Amoxicillin_Oral Susp 125mg/5ml 715,340 Gaviscon Advance_Liq (Aniseed)(Forum) 699,684 Gaviscon Advance_Liq (Aniseed) (Reckitt) 672,413 Oramorph_Oral Soln 10mg/5ml 648,564 Paracet_Oral Susp Paed 120mg/5ml S/F 617,286 Total number of prescriptions** *NHSBSA BNF National prescribing data at presentation level (January 2013 to December 2013). NHSBSA Copyright 2014 **Data based on what is prescribed in England and may include items prescribed in England that have been dispensed in England, Wales or Scotland.

46 Delivering better oral health: an evidence-based toolkit for prevention 43 The list shows that two of the four most prescribed liquids/suspensions/solutions are nutritional supplements which, due to their function, would not be available as sugar free. The table also shows there were almost twice as many scripts for sugar free Amoxicillin Oral Suspension 125mg/5ml than for Amoxicillin Oral Suspension 125mg/5ml. Gaviscon Advance liquid is available in a sugar free version, the table shows that there are more prescriptions for the sugared than sugar free version. Patients need to be made aware that sugar free versions are available and to request these. Where a patient is on long term liquid medication which is not sugar free, clinical teams are advised to check the BNF to see if sugar free alternatives are available. Where a sugar free version is available the clinician should write to the patient s general medical practitioner to ask if they can change the prescription to a sugar free version explaining the reason for the request. Parents should also be advised to discuss with pharmacists if sugar free versions of over the counter liquid medications are available and explain why they should choose these over versions containing sugar. For patients that are dentate and children that are on long term medication that is not sugar free and where sugar free alternatives are not available, patients/parents should be advised where possible to try to take/give medications at mealtimes. This may not always be possible if there are specific instructions such as taking medications on an empty stomach. Dental teams should also reinforce the importance of brushing as the last action before sleep, and that nothing should be eaten or drunk in the last hour before bed. Reference Baqir W, Maguire A, (2000). Consumption of prescribed and over-the-counter medicines with prolonged oral clearance used by the elderly in the Northern region of England, with special regard to generic prescribing, dose form and sugar content. Public Health 2000 Sep 114(5):

47 44 Delivering better oral health: an evidence-based toolkit for prevention 6. Improving periodontal health UK surveys show that some level of irreversible periodontitis affects almost half of all adults (Steele and O Sullivan, 2011) although this might be an underestimate of true disease levels. Periodontal health will therefore be an issue for most patients at one time or other. In view of the chronic nature of the disease, ongoing prevention and management will be the keys to success. Age is not a barrier to good periodontal health (Lindhe et al. 1985, Axelsson et al. 1991, Wennstrom, 1998, Needleman, 2011). Biologically, there is no overall damaging effect of ageing on the periodontal tissues, although changes in cognitive and motor skills might significantly complicate self-care plaque control and treatment. Maintaining periodontal health and preventing the development of periodontitis is based on the following: 1. Prevention of gingivitis. Gingivitis, if not controlled, will lead to periodontitis in the majority of individuals 2. Early detection of periodontitis using the the basic periodontal examination (BPE) 3. Managing risk factors that either increase the risk of developing periodontitis or complicate its successful care 4. Supportive periodontal therapy (maintenance) for patients treated for periodontitis 1. Prevention of gingivitis Gingivitis is a predictor both of developing periodontitis and of increased tooth loss (Lang, Schatzle and Loe, 2009). Prevention of gingivitis is therefore important and is based on maintaining low plaque levels. Successful plaque control will result from a number of factors including: 1. A motivated patient, with appropriate skills, dexterity and oral hygiene kit 2. Effective behaviour change advice and instruction from dental team 3. Teeth, restorations and gingival contours which do not prevent effective plaque control Oral hygiene dental plaque control for periodontal health Oral hygiene should be carefully tailored to an individual s needs and preferences: advise and instruct good plaque removal from, and just into, the gingival crevice including interdental areas advise replacement of toothbrushes regularly, every one to three months encourage daily interdental cleaning before toothbrushing. Since toothbrushing but not interdental cleaning is a routine for the majority of people, carrying out interdental oral hygiene first may link these activities and help develop regularity

48 Delivering better oral health: an evidence-based toolkit for prevention 45 there are many types of interdental aids and personal preference will dominate choice of any individual type. However, in general, people with, or treated for, periodontitis will have larger interdental spaces due to tissue loss and interdental brushes will be more effective than dental floss or tape. The size of the interdental brush should be a snug fit in the interdental space. Therefore many patients with periodontitis will require more than one size of brush for smaller and larger spaces (eg, between anterior and posterior teeth) while there is evidence that some powered toothbrushes (with a rotation, oscillation action) can be more effective for plaque control than manual tooth brushes, it is probably more important that the brush, manual or powered, is used effectively twice daily. Thorough cleaning may take at least two minutes. Brushes should have a small-head with medium-texture bristles and be changed regularly (every one to three months). time spent brushing may be a useful guide for patients. Assessing efficacy in the dental practice is better based on gingival inflammation levels the primary emphasis should be for patients to develop good interdental plaque removal and tooth brushing. Although there is some evidence that fluoride toothpaste containing triclosan and a co-polymer, reduces plaque and gingival inflammation more than toothpastes that contain fluoride only, the clinical relevance of this reduction is unclear (Riley and Lamont, 2013) for patients with limited cognitive and motor skills (eg, children and adults with special needs, frail older people) consider toothbrush adaptations and additional support Behaviour change (see also section 10) Current research shows that brief behaviour change interventions can improve plaque control more than traditional oral hygiene instruction alone. These approaches encourage the patient to understand how oral hygiene might be beneficial to them, to develop confidence in their oral hygiene abilities, to set targets for change that they feel able to achieve and to challenge their perceived barriers to performance. Some of these methods address common barriers to the development of an effective oral hygiene routine which may not otherwise be addressed during traditional oral hygiene instruction. 2. Early detection of periodontal disease The BPE is well known and quick to use (British Society of Periodontology, 2011). Recently, the BPE has been adapted for early detection of periodontal disease in children as it is recognised that periodontitis can start in children and adolescents but is hard to detect without probing (British Society of Periodontology, 2012) Therefore, all children from the age of seven years and upwards should be examined with modifications of the BPE. The summary guidance indicates how to do this in two age bands: seven to 11 years and 12 to 17 years.

49 46 Delivering better oral health: an evidence-based toolkit for prevention Age 7-11 years Gum disease is difficult to identify unless looked for III Teeth to assess: BPE codes to use: 0,1,2 (only) BPE = 0, assess again at routine recall visit or within 1 year, whichever the sooner BPE = 1 or 2, treat and assess again at routine recall or after six months, whichever the sooner Age Gum disease is difficult to identify unless looked for III Teeth to assess: BPE codes to use: 0,1,2,3,4 and * BPE = 0-2 as above BPE = 3 in 1 or more sextant: treat and review after three months BPE = 4 or * in any sextant: full periodontal assessment and normally arrange referral (possible aggressive periodontitis) 3. Managing risk factors Smoking Smoking (and smokeless tobacco products) has a profound effect on the risk of developing periodontitis but also impairs the treatment response. As a result, people with periodontitis who continue to smoke are more likely to lose teeth than non-smokers: checking smoking status for all patients is important. Since smoking status changes with time (non-smokers starting to smoke and people who quit relapsing), review this at oral health assessments for patients interested in quitting following brief advice by the dental team, signpost to local stop smoking services as this is the most effective approach to quitting patients who are not ready or willing to stop may wish to consider using a licensed nicotine containing product to help reduce smoking. The health benefits to reducing are unclear but those who achieve this are more likely to stop smoking in the future For more details see section 7 Diabetes Diabetes increases the risk of developing periodontitis and also may impair the treatment response of periodontitis. While it is true that well controlled diabetes is not a risk factor, many people oscillate between levels of control. Therefore, it is preferable to assume an increased risk for periodontal disease for anyone who has diabetes.

50 Delivering better oral health: an evidence-based toolkit for prevention 47 in addition to usual good practice for periodontal disease prevention, patients with diabetes should be informed of the risk discuss how diabetes control affects periodontal health and ask about their level of glycaemic control, also known as HbA1c. Levels consistently below 7.0% indicate good control. Encourage patients to maintain good diabetes control (diet, medication, exercise etc.) and to follow-up with the diabetes physician regularly write to the diabetes physician for guidance on patient s diabetes status and health (template in appendix 6.1), particularly HbA1c levels. Informing the physician about the patient s periodontitis status might help the physician to tailor diabetes care and advice appropriately Medications There are a number of types of medications that are known to affect periodontal health, which underlines the importance of a comprehensive and up to date medical history. Medications may cause: dry mouth most commonly seen with antidepressants and antihistamines, although a large number of drugs can have this effect (check in formulary) gingival enlargement most commonly seen with calcium channel blockers for cardiovascular disease, although other drugs can have this effect Ask: ask patients on medication if they experience dry mouth/gingival enlargement symptoms Assess: assess oral health for impact of medication, eg, dry mouth: mucosal Action: changes, caries, extensive plaque deposit and candidal infection. Gingival enlargement: gum swelling, especially between teeth explain findings and assess possible need to change medication contact physician to request consideration for medication change oral hygiene consider short-term use of chlorhexidine mouthrinse in addition to usual plaque control review/professional plaque control consider increasing frequency of reviews and scaling 4. Preventing disease in patients treated for periodontitis (supportive periodontal therapy/maintenance) Periodontitis is a chronic disease and will recur and worsen without good plaque control (Axelsson, Nystrom and Lindhe, 2004, Needleman et al. 2005). Support of this is the basis of supportive periodontal therapy (SPT) which requires a long-term commitment from the patient and an intensive level of support, monitoring and care from the dental team. Important components of SPT include: expectations patients should be advised about the importance of SPT and the commitment required prior to commencing periodontal therapy monitoring plaque and gingival inflammation to guide oral hygiene advice probing depths and bleeding on probing to guide:

51 48 Delivering better oral health: an evidence-based toolkit for prevention i. evaluation of health/stability ii. Targeting of treatment oral hygiene advice/behaviour change as covered above debridement removal of supra and subgingival plaque and calculus, root surface debridement of pockets 5mm and deeper with bleeding on probing Peri-implant health The soft tissues and bone around dental implants are at the same risk of inflammation and progressive disease as those around natural teeth. Evidence is accumulating that superficial inflammation (peri-implant mucositis) and true breakdown (periimplantitis) around dental implants are common (Atieh et al. 2013). The principles of prevention and health around implants are the same as around teeth and focus on effective plaque control (Heitz-Mayfield et al. 2014). Monitoring of implants also includes regular checking of soft tissue health visually and by probing. Unresponsive pockets with bleeding and pus and progressive bone loss indicate periimplantitis. At each visit: monitor plaque and marginal inflammation monitor probing depths, bleeding and presence of pus carry out debridement of all supra and subgingival plaque and calculus consider early referral to specialist for unresponsive deepened pocket with bleeding, or pus and progressive bone loss decide on recall interval based on periimplant and periodontal health. References Atieh MA, Alsabeeha NH, Faggion CM Jr, Duncan WJ (2013). The frequency of periimplant diseases: a systematic review and meta-analysis. J Periodontol 2013;84: Axelsson P, Lindhe J and Nystrom B (1991). On the prevention of caries and periodontal disease. Results of a 15-year longitudinal study in adults. Journal of Clinical Periodontology 18, Axelsson P, Nystrom B and Lindhe J (2004). The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. J Clin Periodontol 31, British Society of Periodontology, (2011). Basic periodontal examination (BPE). guidance%20document%20-%20bpe% pdf Guidelines for periodontal screening and management of children and adolescents under 18 years of age. downloads/53_085556_executive-summarybsp_bspd-perio-guidelines-for-the-under-18s. pdf Heitz-Mayfield L J A, Needleman I, Salvi GE and Pjetursson, Bjarni E (2014). International Journal of Oral & Maxillofacial Implants. Supplement, Vol. 29, p p. DOI: /jomi.2013.g5. Lang NP, Schatzle MA and Loe H (2009). Gingivitis as a risk factor in periodontal disease. Journal of Clinical Periodontology 36, 3-8

52 Delivering better oral health: an evidence-based toolkit for prevention 49 Lindhe J, Socransky S, Nyman S, Westfelt E and Haffajee A (1985). Effect of age on healing following periodontal therapy. Journal of Clinical Periodontology 12, Needleman I, Suvan J, Moles DR and Pimlott J (2005). A systematic review of professional mechanical plaque removal for prevention of periodontal diseases. Journal of Clinical Periodontology 32, Needleman IG. Ageing and the periodontal tissues. In: Carranza, Newman, Takei, editors. Clinical periodontology. Chicago: Mosby; Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database of Reviews 2013, Issue 12. Art. No.: CD DOI: / CD pub2. Steele JG, O Sullivan I (2011). Executive Summary: Adult dental health survey The Health and Social Care Information Centre. PUB01086/adul-dent-heal-surv-summ-themexec-2009-rep2.pdf. Wennstrom JL (1998). Treatment of periodontal disease in older adults. Periodontology ,

53 50 Delivering better oral health: an evidence-based toolkit for prevention Appendix 6.1 Template letter for GDP to contact diabetes physician Practice details Diabetes physician details Dear RE: Name: DoB: Address: NHS number if known: I am managing the periodontal health of and I understand they attend your diabetes clinic. As you know, diabetes can increase the risk of periodontal disease and compromise treatment, particularly with unstable glycaemic control (typically HbA1c more than 7.0%). I would therefore be grateful for your advice on their diabetes control and recent HbA1c levels would be helpful. Thank you in advance for your help Yours sincerely Dentist details Copy: Patient s name

54 Delivering better oral health: an evidence-based toolkit for prevention 51 Section 7 Smoking and tobacco use Tobacco use in England continues to kill more than 70,000 people every year, nearly 1,900 of these people die from oral cancer (The Office of National Statistics, 2013). Action by dental teams to reduce tobacco use will help to improve dental treatment outcomes, promote oral and general health and ultimately save lives. The following are key recommendations made in the related publication Smoke free and smiling, those relevant to dental teams are also reproduced within this document for ease of reference: people who use tobacco receive advice to stop and are offered support to do so with a referral to their local stop smoking service dental schools, postgraduate deaneries and other providers and commissioners of dental teaching should ensure that tobacco cessation training is available and meets national standards dental teams are routinely proactive in engaging users of tobacco commissioning bodies implement appropriate measures that support the above recommendations Smoking remains the leading cause of preventable death and disease in England and has a significant impact on health inequalities and ill health. Other forms of tobacco or smokeless tobacco (which are especially prevalent among the South Asian population) also impact on leading a healthy disease-free life (Tsai et al., 2009, Johnson and Bain, 2000). Tobacco use, both smoking and chewing tobacco, seriously affects general and oral health. At least 50 different diseases are caused by tobacco use including various types of cancers, ischaemic heart disease, strokes and chronic lung disease. The most significant effects of tobacco use on the oral cavity are oral cancers and pre-cancers, increased severity and extent of periodontal diseases, tooth loss and poor wound-healing post operatively (Johnson and Bain, 2000). Smokers are seven to ten times more likely to suffer from oral cancer than people who have never smoked (Warnakulasuriya, Sutherland and Scully, 2005) and in long-term regular users of smokeless tobacco this risk is more than 11 times that of a non-user (Prabhakaran and Mani, 2002). Within England, mortality from oral cancer (ICD10 codes: C00-06/ C09-10/C12-14) was 1,883 in 2011 (males, 1,221; females, 662) (The Office of National Statistics, 2013). While the impact of tobacco use on health is alarming, the benefits of stopping are substantial, particularly for people under 35 years of age, who if they quit successfully will have a normal life expectancy (Doll and Bradford Hill, 1954, Jha et al., 2013). As many of the adverse effects of tobacco use on the oral tissues are reversible, this provides a useful means of motivating patients to stop. Whether smoked or chewed, nicotine from tobacco is highly addictive. Consequently stopping is a major challenge for most users.

55 52 Delivering better oral health: an evidence-based toolkit for prevention The majority of cigarette smokers report that they would like to stop, and make many attempts to quit (West and Brown, 2012). While some people (less dependent smokers) seem capable of stopping without any support, the majority of people would benefit from using smoking cessation medications and the support of their local stop smoking service. This is especially true for people who are more dependent on tobacco (Department of Health, 2010). The latest Adult Dental Health Survey (2009) identified that 61% of dentate adults in England reported they attended the dentist for a regular check-up, 10% on an occasional basis and 27% when they had trouble with their teeth (The Health and Social Care Information Centre, 2011). Dental teams are therefore in a unique position to provide opportunistic advice to a large number of healthy people who may use tobacco and need professional support to stop (Chestnutt, 1999). Thirteen percent of women continue to smoke during pregnancy and many of these women attend for free dental treatment (The Health and Social Care Information Centre, 2012). Dental teams working in the primary care, salaried services and in hospitals also have a potentially important role to play in cessation. Surveys indicate that dental teams have an increasingly positive attitude towards tobacco cessation and are becoming more actively involved in the care pathway (John, Thomas and Richards, 2003). All health professionals share an ethical duty of care to provide evidence-based interventions. Although progress has been made, with many dental teams routinely recording information on tobacco use and advising users to quit, there are dental teams who do not routinely offer tobacco cessation advice to their patients. Reducing tobacco use is a key priority for the NHS (Department of Health, 2010) and a major part of the government s tobacco strategy has been to establish a nationwide network of local stop smoking services. These services provide evidence-based treatment and support for users of tobacco. Cessation/ quit rates among smokers who use these services are substantially higher than among those who only receive advice from primary care professionals (West and Brown, 2012). Carr and Ebbert s most recent Cochrane systematic review (2012) demonstrated that tobacco cessation interventions (including smoking cessation) were beneficial and increased quit rates when compared to no care from an oral health professional within a dental setting. This is the first systematic review to demonstrate oral health professionals increasing quit rates within the dental setting (Carr and Ebbert, 2012). A key priority is therefore to ensure that primary care professionals, such as members of a dental team, engage users of tobacco, advise that their local stop smoking service provides the best chance of stopping, and provide a referral to those services. The role of the dental team in supporting people who use tobacco In the vast majority of cases, dental teams will only be involved in delivering very brief advice (VBA) to tobacco users. Use of the following pathway will increase the chance of a successful quit attempt and reduce time of delivery. The National Centre for Smoking Cessation and Training (NCSCT) has developed a simple form of advice designed to be used opportunistically in less than 30 seconds in almost any consultation with a tobacco user. This is VBA and there are three elements to it: 1. Establishing and recording smoking status (ASK) 2. Advising on the personal benefits of quitting (ADVISE) 3. Offering help (ACT).

56 Delivering better oral health: an evidence-based toolkit for prevention 53 A large study of advice given by GPs across England found that smokers were almost twice as likely to try to stop when they received an offer of help, rather than only received advice to stop (Jha et al., 2013). When compared with no advice to smokers, recommending both treatment and support in the VBA, increased the odds of quitting by 68% and 217% respectively (Aveyard et al., 2012). Ask All patients should have their tobacco use (current, ex, never used) established and checked at least annually. The member of the dental team who elicits this information ensures the update of this information in the patient s clinical notes. Advise Having found someone is a tobacco user, the traditional approach has been to warn them of the dangers of use and advise them to stop. This is deliberately left out of VBA for two reasons: 1. It can immediately create a defensive reaction and raise anxiety levels 2. It takes time and can generate a conversation about their tobacco use, which is more appropriate during a dedicated stop smoking consultation There is no need to ask how long someone has used tobacco, how much they use or even what they use (cigarettes, shisha, cigars, chewing tobacco or paan). Stopping use will be beneficial in every case and the details of this are better saved for the stop smoking consultation. The best way of assessing motivation to stop is simply to ask: Do you want to stop smoking/chewing tobacco? Therefore, what VBA involves is a simple statement advising that, the best way to stop is with a combination of support and treatment, which can significantly increase the chance of stopping. Act All tobacco users receive advice about the value of attending their local stop smoking services for specialised help in stopping. Those who are interested and motivated to stop receive a referral to these services. For some people, it might not be the right time to stop. For those not interested in stopping a simple, that is fine but help will always be available, let me know if you change your mind works best. Figure 7.1 Very brief advice on smoking Harm reduction People who are not ready or willing to stop may wish to consider using a licensed nicotine-containing product to help them reduce their smoking. The NICE guidance on Harm reduction: tobacco (PH45) provides the following advice (NICE, 2013). Most health problems are caused by other components in tobacco smoke, not by the

57 54 Delivering better oral health: an evidence-based toolkit for prevention nicotine. Smoking is highly addictive, largely because it delivers nicotine very quickly to the brain and this makes stopping smoking difficult. Licensed nicotine-containing products are an effective way of reducing the harm from tobacco for both the person smoking and those around them. It is safer to use licensed nicotine-containing products than to smoke. People who reduce the amount they smoke without supplementing their nicotine intake with a licensed nicotine product will compensate by drawing smoke deeper into their lungs, exhaling later and taking more puffs. It is recommended that those individuals reducing the number of cigarettes they smoke use a licenced nicotine containing product to give them some therapeutic nicotine which is more likely to reduce the amount that they smoke and to improve their health. Nicotine replacement therapy (NRT) products have been demonstrated in trials to be safe to use for at least five years. There is reason to believe that lifetime use of licensed nicotine-containing products will be considerably less harmful than smoking. Licensed nicotine-containing products are available on prescription, over the counter at pharmacies and on general sale at many retail outlets. If someone indicates that they are interested in trying a harm reduction approach to their smoking then you should inform them that the health benefits from smoking reduction are unclear. However, advise them that if they reduce their smoking now they are more likely to stop smoking in the future. Explain that this is particularly true if they use licensed nicotine-containing products to help reduce the amount they smoke. For more information on harm reduction please access the NICE guidance PH45 Tobacco: harm-reduction approaches to smoking : guidance.nice.org.uk/ph45/ Guidance/pdf/English The VBA process can be found here: To date, over 25,000 people have viewed the promotional film and over 28,000 have accessed the training module. Dental health professionals including hygienists, therapists, nurses, practice managers, receptionists, and dentists have all completed the module. Further information section of the VBA module makes specific reference to Making every contact count and includes a link to this document (Every contact counts, 2012). Published in January 2012, the document emphasised the importance of healthcare professionals using every patient contact as an opportunity to maintain or improve that individual s mental and physical health and wellbeing, including tobacco, diet, physical activity and alcohol. Training and support for dental teams in tobacco cessation As in any area of clinical and preventive practice, appropriate training is essential to enable dental teams to deliver tobacco cessation support and advice. The oral pathology associated with tobacco use and, to a more limited extent, tobacco cessation is taught in detail to undergraduate dental students. Basic training may expose other members of the dental team to other teaching on tobacco cessation.

58 Delivering better oral health: an evidence-based toolkit for prevention 55 Cessation case study The NCSCT Very brief advice on smoking module was made available to medics on the BMJ learning website. The 1,329 BMJ learning users who had taken the module were sent invitations to take part in the survey and followed-up with a reminder a week later. A total of 276 respondents submitted the questionnaire, a response rate of 20.6%. In the year before completing the Very brief advice on smoking module, the average proportion of consultations in which smokers were offered help with smoking cessation by survey respondents was 36.8% (0 100, SD=25.33). Since completing the module, the average proportion of consultations in which smokers were offered help with smoking cessation by survey respondents was 60.4% (0 100%, SD=27.82). This is a really useful module. Has all the information you need and the use of video, slides and MCQ is really engaging. The most advanced and engaging module I have completed on BMJ Learning. [Medic accessing the NCSCT Very brief advice on smoking module hosted by BMJ learning). It s inspiring, and helps to remind me of the point of asking about smoking... [GP, Leicester] Since the development of the Maudsley model of training for stop smoking practitioners in the early 1990s, training for stop smoking practitioners has continued to evolve. In 2003, the Health Development Agency published the set of competencies required to be present in all smoking cessation training courses (Health Development Agency, 2003). In 2010, the NCSCT updated these competences and launched the first nationally recognised accreditation for delivery of smoking cessation for practitioners (National Centre for Smoking Cessation Training, 2014). This training consists of a two-stage knowledge and practice assessment and supporting online training modules. A clear need exists to: support and promote the NCSCT accredited training, therefore ensuring all dental teams are competent to deliver VBA and/or brief interventions in tobacco cessation. The NCSCT offers online courses at pub_training.php, and local stop smoking services may also provide training for teams ensure all dental undergraduate, dental care professional, postgraduate and continuing professional development programmes facilitate access to such training which meets the national quality standards support dental teams to identify smokers and users of smokeless tobacco, raise awareness among them of the associated health risks and provide signposting to their local stop smoking service Training, regardless of whether it occurs in an undergraduate or dental settings, should be consistent and in line with national training standards. The minimum standard that every dental practice member should achieve is Very brief advice, just 30 seconds to ask, advise and act (National Centre for Smoking Cessation Training, 2012).

59 56 Delivering better oral health: an evidence-based toolkit for prevention Case study. Teaching smokingcessation to aspiring members of the dental team The General Dental Council, in its recently published guidance on learning outcomes required for registration, states that members of the dental team should be able to communicate appropriately, effectively and sensitively with patients about smoking (General Dental Council, 2012). At Cardiff University Dental School, teaching smoking-cessation counselling is a vehicle for providing undergraduate dental, dental hygiene and dental therapy students with a number of skills. Changes in smoking patterns are used to teach epidemiology. Psychological theories underlying behaviour change are taught didactically and students also learn why people smoke, what is necessary to motivate behaviour change, and the impact of addictive behaviour. Junior students use role-play techniques to learn how to raise the topic of smoking-cessation in a sensitive manner, enabling them to develop their communication skills. A self-directed learning exercise is used to familiarise student dental hygienists with resources that are available to help patients who are considering stopping smoking and where to direct those patients who want to quit. An awareness of the different forms in which patients from different ethnic backgrounds may use tobacco provides a focus for discussion of how cultural practices may impact on oral health. Assessment of knowledge and competency in this area are tested using objective structured assessments, involving the use of actors to play the role of smokers, with different attitudes to using tobacco. How can dental teams engage with users of tobacco? Local stop smoking services have helped many thousands of people to successfully stop using tobacco. In over 400,000 people, 49% of attendees, stopped by using these services. Indeed, smokers are up to four times more likely to stop if they attend these services and use medication, than by trying to quit on their own without support and medication (West and Brown, 2012). As a result, policy guidance to health professionals now emphasises the importance of referring all who wish to stop using tobacco to their local stop smoking services for specialist assistance and support (National Institute for Health and Clinical Excellence, 2006): the best outcomes occur when those who are interested in stopping take-up a referral for specialist support. Timing is crucially important: the quicker the contact by a local stop smoking service, the greater the motivation and interest in the individual. Dental patients, who express a desire to stop, signposted directly into their local stop smoking services receive the best opportunity to stop smoking. The dental team s role is vital in giving the patient information on how to contact their local stop smoking service. It just takes 30 seconds and can give patients the motivation to seek professional help which will increase their chances of quitting dental teams and the local stop smoking services can work collaboratively in a variety of ways. As a first step, it is important that all members of a dental team are fully aware of the services offered locally and of how these operate. Arranging a meeting with a representative of a local service could provide a useful opportunity for dental teams to learn

60 Delivering better oral health: an evidence-based toolkit for prevention 57 about the service and the best ways of signposting dental patients to it teams working together provide much more support to the patient in stopping smoking. It is important that no matter who makes the referral, the patient s progress in stopping is assessed and is recorded in their clinical notes at each subsequent dental appointment. Stopping tobacco use can be a difficult process and is often associated with a range of unpleasant, short-term withdrawal symptoms, some of which, such as ulcers, directly affect the oral cavity. Reassurance and advice from dental team members may help patients deal more effectively with these problems, thereby increasing their chances of quitting successfully when tobacco users express a desire to stop their dental team can offer advice and support. This advice and support should only be delivered by dental staff trained to the current NCSCT Training Standard and preferably are fully NCSCT certified; having passed the knowledge (Stage 1) and practice (Stage 2) assessments (National Centre for Smoking Cessation Training, 2014). In this case, as with any provider of services, continued commitment to governance and performance monitoring is required to ensure that service users continue to be provided with the best available intervention is effective in helping patients who chew tobacco to stop. Current NICE guidance (National Institute for Health and Clinical Excellence, 2012), regarding smokeless tobacco users in South Asian communities, recommends dental teams: Ask people if they use smokeless tobacco, using the names that the various products are known by locally. If necessary, show them a picture of what the products look like, using visual aids. (This may be necessary if the person does not speak English well or does not understand the terms being used). Figure 7.2 gives an example of a resource that could be used, with details of each product on the reverse. This resource also provides information on shisha (water pipe top left image on resource below) use. Shisha is not a smokeless tobacco product and can be as damaging as smoking cigarettes or chewing any of the smokeless tobacco products listed. Users of shisha, who wish to stop smoking, should be referred to the stop smoking service in the same way as other users of tobacco. Advise the patient of the health risks (eg, the risk of lung cancer, respiratory illness and periodontal disease) (Akl et al., 2010) associated with tobacco use and advise them to stop. Where services exist locally, refer people who want to quit to local specialist tobacco cessation service. Record the outcome in the patient s notes. VBA (ask, advise, act) is the same method you would apply to smokers or smokeless tobacco users. Among certain ethnic minority groups, chewing tobacco and/or areca nut (paan) is a common cultural practice. Evidence indicates that chewing tobacco and other products is associated with the development of oral cancers and other oral pathologies (Carr and Ebbert, 2012, Tsai et al., 2009). A recent Cochrane systematic review showed that advice delivered in dental surgeries

61 58 Delivering better oral health: an evidence-based toolkit for prevention Figure 7.2 Niche tobacco resource developed by Bradford & Airedale stop smoking service Ensuring that referral pathways are quick and easy to use is essential if systematic local delivery of VBA and referrals are to be achieved. Secondary care is one setting that has often been regarded as a missed opportunity when it comes to the identification and referral of smokers. The NCSCT has developed a national electronic referral system in a hospital setting (www. ncsct.co.uk/publication_national-referralsystem.php). This resulted in a 600% increase in referrals to local stop-smoking services in the pilot site and the system has now been adopted by 17 trusts. all dental teams should signpost and offer VBA within their current contractual arrangements. In a small number of cases, dependent upon local need, dental teams may be commissioned to provide a specialist support service (taking patients through a full quit attempt) Further details regarding the commissioning of smoking cessation services within dental teams can be found in the related document Smokefree and smiling (second edition) or from local stop smoking services.